Review Paper

Should Psychologists Be Granted Prescription

Privileges? A Review of the Prescription Privilege
Debate for Psychiatrists
Kim L Lavoie, MA, PhD1, Richard P Fleet, PhD2

Background: The debate over whether clinical psychologists should be granted the right to
prescribe psychoactive medication has received considerable attention over the last 2 dec-
ades in the US, but there has been relatively little discussion of this controversial topic
among Canadian mental health professionals, namely psychologists and psychiatrists. Pro-
ponents of prescription privileges (PPs), including the American Psychological Association
(APA), argue that psychologists do not and cannot function as independent professionals
because the medical profession places many restrictions on their practice. It is believed that
PPs would help circumvent professional psychology’s impending marginalization by in-
creasing psychology’s scope of practice. Proponents also argue that PPs would enhance
mental health services by increasing public access to professionals who can prescribe.
Objective: The purpose of this article is to inform psychiatrists about the major arguments
presented for and against PPs for psychologists and to discuss the major implications of
PPs for both professional psychology and psychiatry.
Methods: We conducted a literature search of relevant articles published from 1980 to the
present appearing on Psychlit and Medline databases, using “prescription privileges” and
“psychologists” as search titles.
Conclusion: Although proponents present several compelling arguments in favour of PPs
for psychologists, pilot projects relating to feasibility and efficacy are either sparse or in-
complete. Thus, it is too soon to tell whether PPs could or should be pursued. Clearly, more
research is needed before we conclude that PPs for psychologists are a safe and necessary
solution to psychology’s alleged impending marginalization.
(Can J Psychiatry 2002;47:443–449)

Clinical Implications

· Granting prescriptive authority to psychologists will have a profound impact on both profes-
sional psychology and psychiatry—both in terms of identity and practice.
· We hope that this article informs psychiatrists and stimulates their interest in the prescription
privilege debate.
· We hope that this article will help psychiatrists assist in the decision-making process.

Limitations

· Conclusions to date are based on relatively few empirical studies.

Key Words: prescription privileges, professional psychology, professional psychiatry,

psychopharmacology

W Can J Psychiatry, Vol 47, No 5, June 2002 443

The Canadian Journal of Psychiatry—Review Paper
ver the last 2 decades, in both the US and Canada, an im-
O portant debate has emerged within professional psychol-
ogy about whether clinical psychologists should be granted
the legal right to prescribe psychotropic medications. The
American Psychological Association (APA) and both Ameri-
can and Canadian psychologists argue that psychologists can-
not function as independent professionals, due to the many
restrictions placed on their practice by the medical profession
(1–3). Proponents argue that prescription privileges (PPs)
may significantly improve patient care and are in the best in-
terests of the profession. Despite receiving considerable atten-
tion throughout the US, there has been relatively little
discussion of this important debate among Canadian mental
health professionals and professional legislative bodies.
Throughout the course of this paper, we present the major ar-
guments for and against PPs for psychologists, followed by a
discussion of the potential impact of PPs on both the profes-
sions of psychology and psychiatry. Given that psychiatrists
will likely be consulted, we hope this article will help inform
them about the major issues surrounding this debate.
History: The Prescription Privilege Debate
Lightner Witmer, who established the first American psychol-
ogy clinic in 1896, originally founded clinical psychology. At
that time, the practice of clinical psychology was conceived as
the application of psychological principles to the study of the
individual (4), but it remained a largely academic discipline
until World War II. During and after the Second World War,
the demand for mental health services to treat the victims of
war increased dramatically, and the Veteran’s Administration
(VA) was forced to expand the role of psychologists to include
psychometrics, interpretation of aptitude, intelligence, and
personality tests, diagnostic interviewing, and psychiatrist-
supervised psychotherapy (5). Interestingly, the APA’s Com-
mittee on Training in Clinical Psychology (CTCP) (6) did not
envision psychotherapy as a central activity for clinical psy-
chologists. Training programs were designed to produce psy-
c hological s cientists by em phasizing r es ear ch,
psychodiagnostics, and general psychology principles. Train-
ing clinicians was secondary in importance. Despite the inten-
tions of the CTCP, many clinical psychologists wanted
psychotherapy to be their central activity and no longer
wanted psychiatrist supervision. Although psychiatry
claimed psychologists lacked proper training, psychologists
ended psychiatry’s monopoly on psychotherapy by the end of
the 1950s (7).
While psychologists were battling psychiatrists for the right to
conduct psychotherapy, modern psychopharmacology
emerged as a major force in mental health care. Between 1950
and 1960, many of the psychotropic medications in use today
were introduced (for example, chlorpromazine, tricyclic
444
antidepressants, and benzodiazepines) (8). At the time, clini-
cal psychologists criticized their efficacy by arguing that they
only treated the symptoms of a disorder, not the underlying
psychological disturbance (9). Psychology’s theoretical ap-
proach to mental illness, unlike psychiatry’s, did not promote
a disease model of mental illness, but rather emphasized ap-
plying psychological-based theories to the understanding and
treatment of mental disorders (10). Consequently, the APA
expended little effort at the time to obtain PPs for clinical psy-
chologists, and licenced physicians retained sole right to pre-
scribe medication.
Who Can Legally Prescribe?
In the US, determining the practitioners with the authority to
prescribe medication generally occurs at the state level.
Through their respective pharmacy and medical practice acts,
each state determines which professions are authorized to pre-
scribe (11). In Canada, the Federal Bureau of Human Pre-
scription Drugs decides how drugs are sold, and provincial
legislatures determine which professions may prescribe. A 2-
factor classification scheme for PPs was established to specify
the degree of prescriptive authority held by a particular pro-
fession. The first dimension (independent vs dependent) per-
tains to whether physician supervision is required to
prescribe. The second dimension (limited vs unlimited) con-
cerns what categories of drugs may be prescribed (12). Only
physicians have independent and unlimited PPs in the US, but
Canada grants independent and unlimited privileges to both
physicians and dentists. Over the years, various professions
have been granted limited PPs in the US, such as dentists, op-
tometrists, and podiatrists. Prescriptive authority for these
professions is limited typically to medications that affect body
parts in their area of practice (11). The APA is currently advo-
cating for independent privileges, which would be limited to
prescribing psychoactive medications.
Other nonphysicians who may be granted some degree of pre-
scriptive authority are called “physician extenders.” Profes-
sions that fall into this category include nurse practitioners,
pharmacists, and physician assistants, whose prescriptive
authority depends on physician supervision and is limited to
specific drugs or drug formularies (13). Note that in Canada,
however, that although podiatrists have limited PPs in the
province of Alberta, no other nonphysician disciplines may
prescribe medication in this country.
Forces Driving the Prescription Privilege
Debate
Understanding the nature and timing of the PP debate involves
recognizing that it is occurring in a larger context of change
within and around the practice of professional psychology.
For years, psychologists have devoted time and energy to
making psychotherapy their central activity, perhaps to the
W Can J Psychiatry, Vol 47, No 5, June 2002
 Should Psychologists Be Granted Prescription Privileges? A Review of the Prescription Privilege Debate for Psychiatrists
detriment of equally important activities such as research and
developing preventive interventions. Now, psychologists face
the possibility that they are no longer required to fulfill their
psychotherapeutic role. Research shows that in most circum-
stances, a doctoral-level psychologist need not deliver psy-
chotherapy to be effective (14,15). Presently, the field
includes master’s-level psychologists, doctorate-level
psychologists, and ever-expanding groups of mental health
professionals who also conduct psychotherapy, namely social
workers, nurses, marriage and family counsellors, occupa-
tional therapists, and sex therapists (10).
Economic factors are also fuelling the debate. Since the end of
the 1980s, the governing force in mental health services in
both Canada and the US has been cost containment. Although
Canada’s health care system has been managed publicly for
decades, the need to reduce health care costs in the US has
contributed to the creation of health maintenance organiza-
tions (HMOs) (16). Canada’s publicly operated system and
the rise of managed care systems in the US are essentially
leading to the replacement of doctoral-level psychotherapists
with less costly psychotherapists, whenever possible (17,18).
Although doctoral-level psychologists may still be required
for training and supervision, there is no longer a reason to use
them as front-line service providers. From a cost-containment
perspective, we expect that this situation will continue as long
as third-party payers decide who conducts psychotherapy.
Similarly, the rising importance of mental health to pharma-
ceutical companies, who have a clear financial interest in the
expansion of prescription authority, is stimulating the debate.
Psychoactive medications now occupy a significant portion of
the drug portfolios of major pharmaceutical firms, and drug
companies are eager to see the use of such drugs expand (18).
Not surprisingly, the APA’s Division of Psychologists in In-
dependent Practice has been sustaining relations with the
pharmaceutical industry over the past few years (19), and
there has been a dramatic increase in drug company-
sponsored symposia for psychologists and training grants for
research “with a strong psychopharmacology emphasis” (20).
Should Psychologists Be Granted Prescription
Privileges?
The following section reviews the major arguments of APA
representatives and both Canadian and American psycholo-
gists in favour of PPs, followed by a section discussing the
weaknesses of those arguments. Further, we discuss the impli-
cations of PPs for professional psychology and psychology.
Arguments in Favour of Prescription Privileges
One of the most popular arguments put forth by PP advocates
is that psychologists do not and cannot function as independ-
ent professionals because the medical profession places many
W Can J Psychiatry, Vol 47, No 5, June 2002
restrictions on their practice in such areas as hospital privi-
leges, insurance reimbursement, and PPs (1,2). Advocates as-
sert that obtaining PPs would help increase the scope of
psychological practice by helping psychologists expand their
practice into settings that are traditionally dominated by phy-
sicians, such as nursing homes, long-term care facilities, and
hospital-inpatient services (3,21).
To support this argument, advocates assert that because
doctoral-level psychologists have more education than do
other professionals who have secured various degrees of pre-
scriptive authority (for example, nurse practitioners and phar-
macists), psychologists should qualify for privileges (22,23).
In fact, it is generally accepted by both proponents and oppo-
nents of PPs, that with the proper curriculum, psychologists
could be trained to prescribe psychoactive medication
(2,18,24). Evidence emanating from both the Department of
Defence Psychopharmacology Demonstration Project (PDP)
and the Indian Health Service (IHS) shows that psychologists
have been trained successfully to prescribe psychoactive
medication (11,24–26).
A second major argument in favour of PPs relates to the lim-
ited mental health training of general practitioners (GPs)
(3,12,22). A recent survey revealed that, of the 135.8 million
prescriptions issued for psychoactive medications in 1991,
psychiatrists issued only 17% of those prescriptions. The re-
maining 83% were issued by GPs who typically receive only 4
to 12 weeks’ training in mental health (27–29). Mental health
training for Canadian physicians appears consistent with this
figure (12). Equally disturbing is the fact that many patients
seen by GPs and other nonpsychiatric specialists are fre-
quently misdiagnosed and prescribed medication unnecessar-
ily. Research shows that, in women alone, depression is
misdiagnosed 30% to 50% of the time, and when antidepres-
sants are prescribed, patients are often improperly monitored
(30). Given these data, proponents of PPs argue that appropri-
ately trained doctoral-level psychologists would be more
qualified to diagnose mental disorders, prescribe appropriate
medication, and monitor the behavioural effects of such medi-
cation than would nonpsychiatrist practitioners (2).
Further, proponents point out that the reason so many GPs pre-
scribe psychoactive medication is due to the relative unavail-
ability of psychiatrists. Thus, advocates claim that granting
PPs to psychologists would benefit those who have limited ac-
cess to psychiatrists (11,31). Similarly, it is argued that PPs
will enable psychologists to provide needed mental health
services to underserved segments of society, such as minority
children, those living in rural areas, and those living in chronic
care facilities (11,31,32).
Advocates for PPs argue that, because many patients receiv-
ing psychotherapy will consult a psychiatrist for
445
The Canadian Journal of Psychiatry—Review Paper
pharmacologic treatment, it would be less disruptive to have 1
treatment provider (a psychologist) who can both prescribe
and conduct therapy. They argue that being forced to consult 2
professionals with potentially contrasting views on how to di-
rect patient care could compartmentalize treatment and force
patients into “divided loyalties” (33–35). The result is ineffi-
cient treatment dissemination and, ultimately, diminished
treatment efficacy. Proponents add that granting prescriptive
authority to psychologists would also result in decreased
health care costs; psychologists charge an average of 14% less
than do psychiatrists for the same service (36). Therefore, pro-
ponents believe PPs for psychologists would facilitate both
treatment and recovery at a lower cost.
A final point argued extensively in the literature is that medi-
cations can influence behaviour. In fact, this is a major target
of psychological research and practice; for this reason, pre-
scribing medications should become part of the practice of
psychology (11,13,22).
Arguments Against Prescription Privileges
Although proponents have presented several compelling ar-
guments in support of granting PPs to psychologists, their ar-
guments suffer from several important weaknesses. First, the
argument that PPs would help psychologists gain professional
autonomy by expanding their scope of practice into settings
traditionally dominated by physicians has little empirical ba-
sis. This argument assumes that PPs will lead to 1) the cessa-
tion or reduction of physician control over inpatient services
and 2) a dramatic increase in the number and type of clients
psychologists can treat. It is unlikely, however, that PPs will
impact which profession controls inpatient services. In short,
control and, ultimately, responsibility of inpatient services is a
public policy issue that is totally independent of the prescrip-
tion privilege issue. Finally, physicians have been opposed to
hospital privileges and any related pursuits thought to en-
croach on what they have considered to be their turf for years
(10,37). Any endeavour that threatens to reduce their power
over inpatient and hospital services will likely be met with a
fight. To automatically equate PPs with physician-like control
over mental health services is therefore perhaps overly
optimistic.
Second, although there is some evidence demonstrating psy-
chologists’ competence to prescribe, the quality of that com-
petence appears to vary according to the source of the report.
For example, DeLeon, Folen, and others (24) reported that no
quality of care problems were revealed following the Defence
Department’s PDP and concluded that psychologists could be
trained as competent prescribers. Conversely, the American
Psychiatric Association’s Legislative Newsletter (12) re-
ported that the doctoral-level psychologists who participated
in the PDP received grades in conventional medical and
446
pharmacological courses that ranged from C– to F. These
grades likely reflect the psychologists’ lack of training in ba-
sic sciences (for example, molecular biology, organic chemis-
try, and physiology), which currently are not required for
admission to psychology graduate programs. A notable differ-
ence between psychologists and the nonphysician professions
with limited PPs is that they all have a solid biological science
background, which most psychology graduate programs do
not provide (38). In fact, a recent survey of graduate students
revealed that only 7% had completed the minimum number of
undergraduate science prerequisites necessary to undertake
psychopharmacology training, as stipulated in proposed train-
ing models (39). Further, surveys of graduate training direc-
tors revealed that 62% to 75% preferred not to train
psychology students to prescribe at the doctoral level, stating
that it would interfere significantly with current programs
(40,41). As a result, currently most doctoral students and psy-
chology training programs in the US and Canada are ill-
prepared or unwilling to pursue psychopharmacological psy-
chology as a subspecialty.
Some evidence documents psychologists’ competence to pre-
scribe, but it is difficult to generalize from so few data. To
date, the literature has published the results of 2 American
projects (the PDP and IHS) (25,26), and we are unaware of
any published trials emanating from Canada. Besides, the
sample sizes (n = 4 and n = 1, respectively), upon which con-
clusions concerning competence have been drawn, have been
small. Clearly, we need more evidence before concluding that
psychologists are capable of prescribing psychoactive medi-
cation safely and effectively.
The argument that focuses on the limited mental health train-
ing of GPs, although convincing, disregards the extensive
medical and pharmacologic training of these physicians,
which is a minimum of 4 to 6 years. Further, given that GPs are
the front-line service providers under the current system, it is
unlikely that PPs for psychologists would significantly alter
health care—seeking behaviour or the number of prescrip-
tions written by GPs, unless GPs decide to refer their patients
to psychologists for pharmacologic treatment. Rather than
adding psychologists to the long list of professionals who can
already prescribe, a more constructive solution would be to
provide greater mental health training for front-line service
providers and to promote greater collaboration between GPs
and psychologists.
Psychologists with PPs could help respond to the mental
health care needs of underserved segments of the population
(those living in rural or regional areas); however, the profes-
sion of physician assistant was created to serve such popula-
tions, but only 3% actually do (42). Advocates have not yet
produced data indicating the number of psychologists seeking
W Can J Psychiatry, Vol 47, No 5, June 2002
 Should Psychologists Be Granted Prescription Privileges? A Review of the Prescription Privilege Debate for Psychiatrists
PPs for this purpose or the number of psychologists who
would relocate to provide services to a rural population.
Advocates for PPs have argued that having a psychologist
who can both conduct psychotherapy and prescribe would be
less disruptive and more effective than consulting both a psy-
chologist and a psychiatrist with “potentially contrasting
views.” However, this argument assumes that psychologists
would be more qualified than would psychiatrists to fulfill this
dual role. If proponents are arguing a lack of collaboration be-
tween psychologists and psychiatrists, the solution appears to
be improving collaboration (for the benefit of the patient) and
not restructuring the practice of psychology.
The assertion that PPs for psychologists would result in lower
mental health care costs is unlikely, given that psychologists
would be in a position (and would likely be highly motivated)
to raise their fees to reflect their new skills. This assertion is
even more unlikely if you consider how insurance premium
costs for psychologists would likely increase in line with their
new responsibilities and potential liabilities. Interestingly,
proponents of PPs discuss these issues rarely.
Proponents assert that because medications influence behav-
iour, prescribing medications should become part of psycho-
logical practice (11,13,22). Subscribing to this argument,
however, implies that psychologists should be able to adopt
any physical intervention that could affect behaviour or psy-
chological functioning, including neurosurgery or electrocon-
vulsive therapy. The boundaries that the different mental
health professions place on their scope of practice are what de-
fine each profession, and these boundaries promote compe-
tency and quality of care among treatment providers.
Rarely discussed among advocates of PPs is the enormous re-
sponsibility associated with having prescriptive authority,
even if that authority is limited to psychoactive medication.
One common problem associated with taking psychoactive
medication is that many patients experience unpleasant and
sometimes severe side effects, which often require appropri-
ate medical treatment (for example, nausea, constipation, sex-
ual dysfunction, abnormal heart rhythms, orthostatic
hypotension, and hypertension) (43). Psychologists, of
course, would be limited to prescribing psychoactive medica-
tion and thus forced to refer their patient to a physician for
treatment of side effects. In addition, there is the issue of po-
tentially dangerous drug interactions, knowledge of which is
crucial for patient health and safety. In other words, psycholo-
gists pursing PPs would require extensive knowledge of drug
interactions involving the entire pharmacologic spectrum,
which has never been the domain of psychology.
Also, rarely discussed in the literature is the potential for self-
prescription among psychologists. Given the disproportion-
ally high rate of suicide resulting from self-prescription
W Can J Psychiatry, Vol 47, No 5, June 2002
overdoses among health professionals (for example, dentists
and physicians) (44–46), this issue warrants further debate be-
fore we open the door to thousands of additional prescribers.
Effects on the Professions of Psychology and Psychiatry
One of the most fundamental and often ignored issues with re-
spect to PPs is the profound effect on the definition and future
direction of professional psychology and psychiatry. Psychol-
ogy has historically been identified with treatments based on
psychological principles (47). The Psychology Profession
Act of Canada (48) specifically defines the practice of psy-
chology as “the application of professional psychological
knowledge for the purpose of diagnosing, preventing, reme-
dying or ameliorating human mental, emotional, behavioural,
or relationship difficulties and to enhance human perform-
ance and mental or physical health.” According to this defini-
tion, psychology’s principal activities involve psychological
and behavioural interventions based on psychological knowl-
edge, not psychiatric or pharmacologic knowledge; thus, pre-
scribing psychoactive medication clearly falls outside the
boundaries of what has been considered psychological
practice.
If psychologists were permitted to add medication to the list of
interventions they currently use, the underlying rationale and
organizing principles of both psychology and psychiatry
would be fundamentally altered. Psychiatry is a medical disci-
pline, focusing on the diagnosis and treatment of mental dis-
ease; psychology was originally conceived as an academic
discipline. Only later did it evolve to include psychological,
cognitive, and behavioural approaches to both evaluating and
treating mental illness. Psychology, however, has grown to
develop innovative and effective treatments for several men-
tal disorders, which should remain distinct from psychiatric
approaches.
Conclusions
The debate on whether psychologists should be granted PPs is
still in its infancy. Pilot projects relating to feasibility and effi-
cacy are either sparse or incomplete. Although proponents
present several compelling arguments in favour of PPs for
psychologists, it is too soon to tell whether PPs could or
should be pursued. What is clear is that this debate will have a
profound impact on both professional psychology and psy-
chiatry—but one that is likely to take years to unfold.
In the meantime, psychologists could concentrate their efforts
on improving both the professional and public dissemination
of the services they already provide. For example, they could
work on improving collaboration with GPs and psychiatrists
to ensure that medicated patients are properly monitored and
advised of available psychotherapy options. Psychologists
need not go beyond the boundaries of psychological practice
447
The Canadian Journal of Psychiatry—Review Paper
to expand into new treatment areas. There have already been
important advances in the areas of health psychology and be-
havioural medicine, wherein psychologists have demon-
strated success in improving treatment adherence and disease
outcome in cancer patients (49–51), coronary artery disease
patients (52,53), and HIV sufferers (54,55), all using psycho-
logical interventions. Expanding the quality and scope of ex-
isting psychological therapies, rather than expanding services
to include PPs, may represent more promising and appropri-
ate goals for psychology at the present time.
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Manuscript received June 2001, revised November 2001, and accepted April
2002.
1
Psychologist, Montreal Heart Institute and Sacre-Coeur Hospital, Montreal,
Quebec.
2
Associate Researcher, Montreal Heart Institute; Director of Clinical Re-
search, Department of Psychiatry, Sacre-Coeur Hospital; Adjunct Professor,
Department of Psychology, University of Quebec at Montreal, Montreal,
Quebec.
Address for correspondence: Dr Kim L Lavoie, Montreal Heart Institute, Re-
search Center, 5000 Belanger East, Montreal, QC H1T 1C8
e-mail: kiml_lavoie@yahoo.ca
W Can J Psychiatry, Vol 47, No 5, June 2002
 Should Psychologists Be Granted Prescription Privileges? A Review of the Prescription Privilege Debate for Psychiatrists

Résumé : Doit-on accorder aux psychologues le privilège de prescrire? une étude

du débat sur le privilège de prescrire à l’intention des psychiatres
Contexte : Le débat sur la question d’accorder ou non aux psychologues cliniques le droit de pre-
scrire des psychotropes a reçu une attention considérable au cours des 20 dernières années aux États-
Unis, mais il y a eu relativement peu de discussions sur ce sujet controversé parmi les professionnels
de la santé mentale canadiens, notamment les psychologues et psychiatres. Les partisans du privilège
de prescrire (PP), y compris l’American Psychological Association (APA), font valoir que les psy-
chologues ne fonctionnent pas comme des professionnels indépendants et ne peuvent le faire parce
que la profession médicale impose de trop nombreuses restrictions à leur pratique. On croit que le PP
aiderait à contourner la marginalisation imminente de la psychologie professionnelle en augmentant la
portée de la pratique de la psychologie. Les partisans soutiennent également que le PP améliorerait les
services de santé mentale en élargissant l’accès du public aux professionnels qui peuvent prescrire.
Objectif : Le but de cet article est d’informer les psychiatres sur les principaux arguments présentés
en faveur et en défaveur du privilège de prescrire (PP) pour les psychologues, et de discuter des prin-
cipales implications du PP tant pour la psychologie professionnelle que pour la psychiatrie.
Méthodes : Nous avons mené une recherche des articles pertinents de la documentation dans les
bases de données Psychlit et Medline, publiés de 1980 à aujourd’hui, à l’aide des mots clés « privilège
de prescrire et psychologues ».
Conclusion : Bien que les partisans présentent plusieurs arguments convaincants en faveur du PP
pour les psychologues, les projets pilotes sur la faisabilité et l’efficacité sont soit rares, soit incom-
plets. Ainsi, il est trop tôt pour dire si l’on peut ou doit poursuivre le PP. Il est évident qu’il faut
d’autres études avant de conclure que le PP pour les psychologues est une solution sûre et nécessaire
à la présumée marginalisation imminente de la psychologie.

W Can J Psychiatry, Vol 47, No 5, June 2002 449